Special Report

Figure: SIT, EP wellness, EP trainingAlways a stressful specialty, emergency medicine over the past two years has hit never-before-seen levels of intensity, with overloaded waiting rooms, hospitals cycling in and out of crisis, and providers fearing for their health and safety. A poll from the American College of Emergency Physicians found that 87 percent of emergency physicians reported—not surprisingly—feeling more stress since the start of the pandemic. (Oct. 26, 2020; https://bit.ly/34KmJv8.) Experts argue that in an environment like this, stress inoculation training (SIT) is more important than ever as part of the toolbox to prepare emergency physicians, especially residents, fellows, and new attendings, to respond effectively in the moment and cope with the crisis situations they experience on the job. Originally developed by Canadian psychologists Donald Meichenbaum, PhD, and Roy Cameron, PhD, in the 1970s, SIT is a three-step cognitive behavioral therapy that has been used as therapy for post-traumatic stress disorder (PTSD), as well as to help prepare military and law enforcement personnel react appropriately in stressful situations. SIT is less common in health care, but a number of studies and pilot projects over the past several years have assessed whether this approach can help prepare emergency physicians and other health care professionals to work through the stressors and challenges they encounter in a real-world clinical environment. “You don't need an expert to tell you that the ED is stressful,” said pediatric emergency physician Todd Chang, MD, an associate professor of clinical pediatrics at the Keck School of Medicine at the University of Southern California and the associate fellowship director for the pediatric emergency medicine fellowship at the Children's Hospital of Los Angeles. “But we've always emphasized the idea of education: If you just have enough training, you'll perform fine.” But Dr. Chang said education is not sufficient in high-stress, high-cognitive-load situations where a lot is happening. That level of stress makes usual decision-making education harder to access. “Historically we've embraced the idea that the best training programs in EM have lots of patients and total chaos, so you learn by doing,” he said. “Getting thrown into the deep end of the pool inoculates you to the level of stress you're experiencing. But many people don't learn well from that or the stress is too overwhelming.” SIT includes three steps: Providing information: Participants prepare by learning about the human stress response and the conditions they will encounter that can produce it. Acquiring skills: Participants obtain the behavioral, technical, and cognitive skills they will use in a stressful situation. Application and practice: Participants practice those skills in conditions that simulate the stressful environment they will ultimately be in. A Small Part of the Total “Some people think SIT in emergency medicine is just the third point,” said Michael Lauria, MD, an emergency medical services fellow at the University of New Mexico and a flight physician with Lifeguard Air Emergency Services. “They see it as just stress exposure, taking people and putting them in different airway management or trauma scenarios and making them harder and harder to the point where the person is completely stressed out. That's part of the paradigm but just a small part of the total package of SIT.” He explained SIT using an example from the original Meichenbaum research, which involved a person who had experienced a traumatic event on a bus and afterward became overwhelmed by PTSD every time he saw a bus. “In step one, they would explain to the person what was going on physically and psychologically to cause that stress response every time they were near a bus,” Dr. Lauria said. “Then in step two, they would expose the person gradually to more and more information about buses. They'd look at pictures of buses and discuss bus routes,” he said. “Then they'd go outside and look at a bus and go back inside. Then they'd go to a bus stop and leave, then get on a bus and get right back off. During all of the steps of this phase, they would be working on psychological skills like breathing, cognitive reframing, positive self-talk, and mental rehearsal to control their stress response. Only after all of that would they actually go to step 3, riding the bus.” The second phase, said Dr. Lauria, is a critical component of SIT and one that is often glossed over, particularly in the medical setting. “This process of skill building and preparation, such as airway skills, drawing up meds, pushing them quickly and safely, managing hemodynamics—all of that takes a while and you have to build it up slowly for people to really grasp it and become facile with it,” he said. “We commonly say that once you can do these things pretty well, you're good to go, but that's not necessarily the case.” Even after a young physician can complete a task or skill without mistakes, a prolonged period follows where they're getting faster and developing muscle memory and automaticity, Dr. Lauria said. “Only then are you able in a challenging situation to free up mental bandwidth to think about more complex things that are novel or not part of any regime you've seen before instead of thinking about which laryngoscope blade to use,” he said. “That's when we can push step 3, true stress inoculation, making things harder with intrinsic factors like a more complex patient, extrinsic factors like an annoying bystander or equipment failure, and socioevaluative factors such as attendings watching closely.” Pushing step 3 of SIT can be counterproductive, Dr. Lauria said. “Building confidence is one of the whole goals of this process. If you stress the person out too early and make them feel completely overwhelmed, you've destroyed that confidence and get the opposite effect from what you want.” Demands on Faculty Studying SIT in the medical setting is intense and resource-intensive, and efforts to understand how it can best be used are stymied by a number of factors, including demands on faculty and resident time, lack of simulation space, and the pressures of the pandemic. Dr. Lauria's group had been planning a prospective randomized controlled SIT trial with airway management when COVID-19 brought that effort to a halt. “There are a lot of questions about the best way to incorporate SIT into emergency medicine training,” he said. “Are there abbreviated ways to do this? How much of step 1 and step 2 do you really need before adding on the stressful scenarios is helpful? It's more than we're currently getting, but I surmise that it may not be as much as we initially thought.” Until they were interrupted by COVID, Dr. Chang and his colleagues were studying the use of virtual reality in SIT using head-mounted virtual reality devices to recreate as closely as possible the experience of stressful ED scenarios. “For most residents, the scariest cases are the infants who crash, so we went with that kind of scenario (infant status epilepticus and pediatric anaphylactic shock),” he said. “We rented out a motion capture studio to add to the sense of realism, aiming for real psychological fidelity, with the alarms going off, the mother crying in the background, trying to replicate the true stress of the ED.” They recruited 19 attendings and fellows and 15 residents to complete the simulation at its highest setting with high distractions. (Simul Healthc. 2021;16[6]:e219.) Dr. Chang and his colleagues noted a higher level of stress as measured by heart rate and salivary cortisol levels in younger residents compared with older attendings and fellows. “The higher cortisol levels among residents indicate that VR induced a level of stress among novices but not among more experienced and inoculated practitioners,” they wrote. “Our data add to the evidence that the VR is portraying the stressful clinical scenario appropriately. However, it also provides evidence that seasoned attendings have been stress inoculated through real resuscitation experiences. Therefore, providing novice learners with simulations that approximate real resuscitations could have potential as stress inoculation.” Trend Toward Improvement They continued to adapt their VR SIT scenario after that pilot. “When COVID hit, we were in the middle of a study examining whether or not a single VR SIT episode changed behavior or diagnostic reasoning in a stressful situation,” Dr. Chang explained. “It will likely remain unpublished, unfortunately, because the virus meant that we couldn't finish.” That trial was set up to have one group of residents go through virtual reality training in an infant status epilepticus scenario and then have a second train with a mannequin. Both groups would then do a follow-up mannequin-based simulation with a similar case scenario. “We hypothesized that the VR students would do better because of that experience,” said Dr. Chang. “We were unable to complete the second group who just had mannequin-based simulations, but we did see a trend toward improved performance in the simulation group.” Residents in the VR scenario were forced to complete steps in the proper order. “If you have a seizing baby, you have to take care of airway, breathing, and circulation before you order antiseizure meds,” Dr. Chang said. “In the VR, you are unable to order the meds until you go through ABC—there's a block in the program; the nurse says no and eventually hints at what you need to do. Our research coordinator was trained to do the same responses in the mannequin-based scenario.” The study did not have a sufficient sample size to assess significance because it was interrupted early, but Dr. Chang said an interim analysis showed a trend that participants were responding in a way that was closer to the prescribed algorithm if they had the VR experience. “The control group had a tendency to reach for seizure meds earlier before giving airway measures, but the value did not reach statistical significance,” he said. “And we did see a trend that all participants had lower salivary cortisol levels over time. We do think that a controlled level of stress imprints on your memory really well. With VR we can create a level of stress that is curated so that it is not too much, while at the same time it imparts some level of education.” Dr. Chang noted that these simulations show that the body's physiological response to stress carries forward for hours afterward. “This suggests that the way we handle our shift scheduling should perhaps change,” he said. “There may be more optimal approaches through shift stacking and cascading that give physicians a little more than 12 hours between shifts. The opportunities to have physiological rest are paramount for stress recovery.” Share this article on Twitter and Facebook. Access the links in EMN by reading this on our website: www.EM-News.com. Comments? Write to us at [email protected]. Ms. Shawis a freelance writer with more than 20 years of experience writing about health and medicine. She is also the author of Having Children After Cancer, the only guide for cancer survivors hoping to build their families after a cancer diagnosis. You can find her work athttp://www.writergina.com/Home.html. Follow her on Twitter@writergina.

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